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Produced by Allergan – • Date of preparation: NOV. 2016

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Introducing the MD Codes™

Facial aesthetics medicine is constantly evolving, with the development of cutting-edge

products and innovative new ways to use them. With almost endless treatment possibilities,
it is essential that we understand how to achieve the best results for our patients.
For the first time, this book introduces a series of practical injection strategies – or treatment
codes – resulting from over 20 years of my clinical experience. The MD Codes™ allow injectors
to optimise a patient’s facial features in a simple and effective way. With the versatility of
the next generation of hyaluronic acid dermal fillers – Allergan’s VYCROSS® & HYLACROSS™
Collection* – we now have the key to unlocking the code to facial revitalisation.

Why use the MD Codes™?

The MD Codes™ are designed to raise awareness that each aesthetic facial unit (e.g. cheek,
chin, lips etc.) comprises subunits that must be respected during injection. These subunits –
the MD Codes™ – are the structural sites that will create or recreate the most desirable natural
facial architecture for our patients. 
By introducing specific terminology and patterns into the MD Codes™, I was able to
standardise treatment plans and better understand the complexity of the human face.
I developed this simple and practical guide especially for the VYCROSS® & HYLACROSS™
Collection* to assist injectors to achieve optimal results through personalised facial aesthetic
treatment plans.

How do the MD Codes™ work?

Each patient has different motivations and specific needs. The MD Codes™ can be used
to facilitate Financial planning, Assessment, patient Communication, and Technical strategy
(FACT). Product and volume recommendations for each of the MD Codes™ are also provided.

The VYCROSS® & HYLACROSS™ Collection

The VYCROSS® & HYLACROSS™ Collection is designed to address the needs of all areas of the face with just three products:
Juvéderm® ULTRA XC™, Juvéderm® ULTRA PLUS XC™ and Juvéderm® VOLUMA® with Lidocaine.
The versatility of the VYCROSS® & HYLACROSS™ Collection in combination with the MD Codes™ marks a significant leap forward
in the field of medical aesthetics. Together, they bring a new level of sophistication to procedures and provide standardisation.
Knowing that all of our patients want to look their best, the MD Codes™ are the recipe and the VYCROSS® & HYLACROSS™
Collection provides the best ingredients to guarantee quality and safety in our clinical practice.
I hope that you will find the MD Codes™ insightful, practical and useful.
* The VYCROSS® & HYLACROSS™ Collection includes:
Juvéderm® VOLUMA® with Lidocaine, Juvéderm®
ULTRA XC™ and Juvéderm® ULTRA PLUS XC™.

Dr Mauricio de Maio, The MD Codes™ have been developed by

Dr de Maio and all recommendations presented
Plastic Surgeon, Brazil in this guide are based on his clinical experience.
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Contents

The VYCROSS® & HYLACROSS™ Collection of hyaluronic acid fillers 4

The MD Codes™ 5
Why use the MD Codes™? 6
Language of the MD Codes™ 7
The MD Codes™ and the VYCROSS® & HYLACROSS™ Collection 8
Gender differences 9
Injection device 9
Injection delivery 10
Targeted structures 10
Injection technique 11
Alert areas 11
The 3-point forehead reshape 12
The 2-point temple reshape 16
The 3-point eyebrow reshape 20
The 3-point lateral periorbital reshape 24
Danger and alert zones 28
References 29
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The VYCROSS® & HYLACROSS™ Collection of hyaluronic acid fillers

Volume loss is a fundamental component of facial ageing.1 Contributing factors include fat redistribution, skeletal remodelling
and other changes in tissue composition.1 Hyaluronic acid fillers are an established means of addressing volume loss, correcting
contour defects, and providing support and structure to the face.
Hyaluronic acid is a natural polysaccharide polymer present in the human dermis.2 Due to its chemical structure, it is highly water
soluble and will readily dissolve in water to form a viscous clear liquid.2 The hydrophilic nature of hyaluronic acid means it plays an
essential role in the regulation and maintenance of hydration within tissues.3
The hyaluronic acid in fillers is stabilised by crosslinking to increase longevity, as uncrosslinked hyaluronic acid will only remain in
the skin for a few days before being degraded.4 Structurally, hyaluronic acid fillers are similar to native tissue, providing excellent
biocompatibility and good tissue integration.4 Specific physiochemical properties vary by product, determining its clinical
performance and suitability for particular applications.5
The VYCROSS® & HYLACROSS™ Collection, manufactured by Allergan, comprises hyaluronic acid fillers designed to meet the
specific anatomical needs of different facial regions.

Unique crosslinking technology

VYCROSS® technology is a proprietary 6 mix of low and high molecular weight hyaluronic acid, combined with a crosslinking
process, which results in an efficiently and tightly crosslinked gel.3,5,7–9
This tight hyaluronic acid network results in:
• Greater resistance to degradation, delivering long-lasting duration.3,7–9
• Minimal gel expansion due to low water uptake coupled with low hyaluronic acid concentration.3,9
This patented technology 6 allows the customisation of gel hardness (G’) and cohesivity, resulting in products with
optimised lift and mouldability.3,5,7,9
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The MD Codes™

The face can be split into separate anatomical units (e.g. eyebrows, cheeks, lips etc.). The MD Codes™ are a series of precise sites
(or subunits) within each unit that are designed to guide injection. They are based on the principle that facial units have to be
rebuilt, or treated, in an architectural mode.
Each injection site is represented by a combination of letters and numbers. The letters represent the anatomical unit and the
numbers indicate the sequence in which the injections may potentially be delivered. The most important injection site in a
particular anatomical unit is represented by the number 1 and this should usually be the starting point. Injection site number 3
is typically an alert zone, and care should be taken in these areas. Every patient will have a specific sequence and may not need
all of the MD Codes™ in the anatomical unit – each patient should be assessed and treated individually.
Besides letters and numbers, the injection sites are also coloured and represented by different shapes. The colour red represents
an “alert zone”, indicating that the injector should be aware of and avoid important anatomical structures in the area, such as
neurovascular bundles. Shapes are used to indicate technical delivery: a triangle indicates fanning; a circle indicates a bolus;
and a rectangle indicates linear injection.

Summary:

Each code is depicted with a combination of the following:

Letters The anatomical unit (e.g. Ck=cheeks)

Numbers The subunits of the anatomical unit (e.g. Ck1=zygomatic arch; Ck2=zygomatic eminence)

The side of the face (e.g. Ck1r is the zygomatic arch on the right hand side; Ck1l is the
Number location
zygomatic arch on the left hand side)
Superscript (X n) refers to upper areas (e.g. Lp1=vermillion body of the upper lip)
Number position
Subscript (X n) refers to lower areas (e.g. Lp1=vermillion body of the lower lip)

Colours Alert areas denoted in red

Shapes Technical delivery of the product

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Why use the MD Codes™?

The MD Codes™ are a useful tool to help patients understand their treatment motivation. By presenting the MD Codes™ to
the patient, they will point out the areas of concern so that the injector may discuss the appropriate codes for their individual
treatment plan.
Patients are typically unaware of the precise injection sites for their areas of concern. The face is a mechanical structure with hard
and soft tissues that need support to cope with gravity. For instance, the treatment of the cheekbone area with volumisers may
improve the appearance of the nasolabial fold and the lid-cheek junction. The MD Codes™ can help the patient to understand
why the improvement of a target area may be achieved by treating a neighbouring or distal area.
The MD Codes™ are treatment patterns that guide the spotting of injection points on the patient’s face, according to their
individual treatment needs. They represent not only specific sequences of injection points but also act as a tool to facilitate
the communication between patient and doctor.
In addition, the MD Codes™ can be used to aid financial planning and patient follow up.

Summary:

The MD Codes™ are a landmark in facial aesthetics, it’s a FACT

Finance Patients come with a specific budget

Assessment Accurate diagnosis must be made

Communication Clarify “Patient wants vs. Patient needs”

Technique Precise and safe injection can help achieve desired outcomes

The MD Codes™ have been developed by Dr Mauricio de Maio and all recommendations presented in this guide are
based on his clinical experience. The injector is responsible for customising the MD Codes™ for each individual patient.
The Directions For Use document for each product should be respected and product indications noted.
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Language of the MD Codes™

The MD Codes™

L The 8-point lift Ck The 5-point cheek reshape

F The 3-point forehead reshape NL The 3-point nasolabial reshape

T The 2-point temple reshape Lp The 8-point lip reshape

E The 2-point eyebrow reshape M The 3-point marionette lines reshape

G The 2-point glabellar treatment C The 6-point chin reshape

O The 3-point lateral periorbital reshape Jw The 5-point jawline reshape

Tt The 3-point tear trough reshape

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The MD Codes™ and the Juvéderm® Range

The treatment codes provided in this book include guidance on product, choice of injection device, technique and a suggested
volume range. These recommendations are based on the clinical experience of Dr de Maio and may be adapted based on the
experience of the injector and the patient’s facial features.

Product selection
The VYCROSS® & HYLACROSS™ Collection of hyaluronic acid fillers includes:

Juvéderm® VOLUMA® Intended to restore volume of the face, for example, in temples, midface region,
with Lidocaine chin and jaw (≤2 ml per treatment area per session)10

Treatment of deep skin depressions, face contouring and volume restoration to

Juvéderm® ULTRA PLUS XC™ correct facial structural defects such as asymmetry, contour deformities, volume loss
in the lips, cheeks, chin, lower face…etc.11

Treatment of any fine lines and medium-sized skin depressions. Enhancement

Juvéderm® ULTRA XC™ and pouting of the lips to correct structural defects such as asymmetry, contour
deformities, volume loss…etc.12

Please read the appropriate Directions For Use document prior to injecting10–12

General aseptic precautions

The presence of active bacterial or viral infection should postpone treatment.10 –12
Maintaining an appropriate aseptic environment will help reduce the risk of infection. Ensure the patient has removed any
makeup and prepare the skin with antibacterial soap or alcohol.13
Wash your hands, wear appropriate clothing, and use sterile or disposable gloves and equipment. Ensure you have everything
you need before you start injecting.
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Gender differences

Gender differences should be taken into account when individualising treatment.

Recommended for men Injection point for a more masculine outcome

Recommended for women Injection point for a more feminine outcome

Injection device
The choice of injection device should be based on individual experience and preference.

• May minimise risk of intravascular injury and bruising

Cannula
• Recommended for use in alert zone areas

• May be preferred for fine, controlled injections

Needle
• Ideal for bolus at the supraperiosteal level

• Injection of Juvéderm® VOLUMA® with Lidocaine with the supplied 27G 1/2” sterile needle is recommended.10
Use of a cannula where mentioned is the recommendation of Dr de Maio.*
• Injection of Juvéderm® ULTRA XC™ with the supplied 30G 1/2” sterile needle is recommended.
It is possible to use a 30G sterile cannula.12
• Injection of Juvéderm® ULTRA PLUS XC™ with the supplied 27G 1/2” sterile needle is recommended.
It is possible to use a 25G, 27G or 30G sterile cannula.**11
* Use of cannula with Juvéderm® VOLUMA® with Lidocaine has not been validated by Allergan
** For lip indication, the use of 25G cannula is not recommended. Please refer to directions for use
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Injection delivery

Micro-aliquot Very small droplet of filler (0.01–0.05 ml per point)

Aliquot Static injection of a small amount of filler (0.1 or 0.2 ml)

Small bolus Static injection of filler (<0.3 ml)

Linear Antegrade or retrograde

Fanning Multiple linear injections via a single entry site creating a fan-like pattern

Targeted structures

Dermal Mucosa

Subcutaneous / fat pads Supraperiosteal

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Injection technique

1. Aspiration is highly recommended during deep injections close to the bone.

2. Avoid scratching the periosteum during injection, it can lead to pain and bleeding. The technique and depth of the injection
vary depending on the area to be treated.
3. Massage gently following injection to ensure tissue integration and even distribution of the product. A more robust massage
may be needed in deeper planes with a higher volume.
4. When creating structure, remember that indirect changes may happen in neighbouring or distal areas.
5. Younger patients with mild-to-moderate deficiencies may require smaller volumes than older or more complex patients.
6. Do not inject more than 2 ml of Juvéderm® VOLUMA® with Lidocaine per treatment area in a single session.

Alert areas
1. To minimise the risk of injury to blood vessels and nerves, standard precautionary measures should be taken in all areas
of the face. These include injecting slowly and frequently checking for signs of pain and skin colour changes.
2. Alert areas are highlighted with a caution sign, where needle aspiration is highly recommended or the use of cannulas
should  be considered.
3. Standard injection technique should include reflux/aspiration of the syringe plunger to check if blood is drawn into
the chamber. If blood is detected, withdraw the needle, compress and choose a different site. It is important to prime
before injecting.

• High-risk areas where additional caution must be taken if injecting at or

near these sites
Alert area
• A
 lert areas may be highly vascular, highly innervated or adjacent to critical
structures or organs

Do not inject • Areas to avoid injecting with dermal fillers

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The 3-point forehead reshape

The 3-point forehead reshape: Surface anatomy

F2 F1 F3
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The 3-point forehead reshape: Injection areas and effects

Code Injection area Effect of injection Structures affected

F1 Medial forehead

Reshapes the forehead

and improves the appearance
F2 Lateral forehead Deep support
of forehead lines

F3 Central forehead
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The 3-point forehead reshape: Topographical anatomy

F2 F1 F3 F2 F1 F3

2 cm

F1 alert: Be wary of the supraorbital artery

F3 alert: Be wary of the supratrochlear artery

Injection should be avoided in the 2 cm region above the orbit

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The 3-point forehead reshape: Product and volume recommendations

Volume Injection Injection Targeted

Code Product Notes
range (ml) technique device structure

F1 0.1– 0.3 Supraorbital

artery

Juvéderm® ULTRA
F2 0.2– 0.5* or or
PLUS XC™

F3 0.1–0.2 Supratrochlear
artery

* The total volume should be delivered in small boluses (<0.3 ml)

When direct approach to the lines is needed, use Juvéderm® ULTRA XC™

Volume Injection Injection Targeted

Code Product Notes
range (ml) technique device structure

F1 0.1–0.3 Supraorbital
artery

F2 Juvéderm® ULTRA XC™ 0.1–0.3

F3 0.1–0.3 Supratrochlear
artery

These recommendations are provided by Dr Mauricio de Maio and are based on his clinical
experience. Some of these recommendations (e.g. volume, injection device, targeted structure)
may not be aligned with the product Directions for Use, please consult these documents before
using these products.
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The 2-point temple reshape

The 2-point temple reshape: Surface anatomy

T2
T1
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The 2-point temple reshape: Injection areas and effects

Code Injection area Effect of injection Structures affected

T1 Anterior temple
Reshapes the temple Deep support
T2 Posterior temple
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The 2-point temple reshape: Topographical anatomy

T2

T1

T2
T1
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The 2-point temple reshape: Product and volume recommendations

Volume Injection Injection Targeted

Code Product Notes
range (ml) technique device structure

T1 0.2– 0.5* Aspiration

is highly
Juvéderm® VOLUMA® recommended
with Lidocaine
Avoid deep
T2 0.3– 0.5* temporal arteries

* The total volume should be delivered in small boluses (<0.3 ml)

The volume range may vary according to the degree of severity:

• Mild deficiencies up to 0.5 ml per side per session.
• Moderate deficiencies up to 1 ml per side per session.
• Severe deficiencies up to 2 ml per side per session. A total of 2– 4 boluses may be required.

These recommendations are provided by Dr Mauricio de Maio and are based on his
clinical experience. Juvéderm® ULTRA XC™ can be used to treat fine lines and wrinkles
in this area, please consult the Directions for Use document.
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The 3-point eyebrow reshape

The 3-point eyebrow reshape: Surface anatomy

E3 E2
E1
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The 3-point eyebrow reshape: Injection areas and effect

Code Injection area Effect of injection Structures affected

E1 Eyebrow tail

E2 Eyebrow centre Lifts and projects the eyebrow Fat pads (ROOF)

E3 Eyebrow head

ROOF=Retro-orbicularis oculi fat

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The 3-point eyebrow reshape: Topographical anatomy

E2
E3
E1 E1
E2 alert: Inject lateral
to the supraorbital
foramen

E3 alert: Inject lateral

to the supratrochlear
foramen

E3 E2
E1 E1
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The 3-point eyebrow reshape: Product and volume recommendations

Volume Injection Injection Targeted

Code Product Notes
range (ml) technique device structure

E1 0.1– 0.2 or or
Inject slowly
Juvéderm® ULTRA and protect
PLUS XC™ the upper eyelid
with your finger
E2 0.1– 0.2

or
E3 0.1– 0.2

These recommendations are provided by Dr Mauricio de Maio and are based on his clinical
experience. Some of these recommendations (e.g. volume, injection device, targeted structure)
may not be aligned with the product Directions for Use; please consult these documents before
using these products.
NOTE: Juvéderm® ULTRA XC™ can also be used to treat fine lines in this area.
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The 3-point lateral periorbital reshape

The 3-point lateral periorbital reshape: Surface anatomy

O3

O1

O2
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The 3-point lateral periorbital reshape: Injection areas and effects

Code Injection area Effect of injection Structures affected

O1 Central periorbital

Improves the appearance

O2 Lower periorbital of static lines and volume loss Subdermal
in the lateral periorbital area

O3 Upper periorbital
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The 3-point lateral periorbital reshape: Topographical anatomy

O3

O1

O2

O3 alert: Avoid injecting into the upper eyelid

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The 3-point lateral periorbital reshape: Product and volume recommendations

Volume Injection Injection Targeted

Code Product Notes
range (ml) technique device structure

O1

O2 Juvéderm® ULTRA XC™ 0.2– 0.5

O3
Upper eyelid

These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience.
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Danger and alert zones

Whenever injecting into a danger or alert zone, knowledge of
topographic anatomy is essential. For safety reasons, some of these
areas should be treated using a blunt cannula.
When injecting close to the bone or in an alert zone with needles,
aspiration is highly recommended.

G2 E3

G1
Tt3

L3 Tt1 Ck3
NL1
Jw3

L8 Ck5

Be careful when injecting

close to the highlighted areas
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References

1. Hoffmann K. et al. BMC Dermatology 2009;9:9.

2. Tezel A and Frederickson GH. J Cosmet Laser Ther 2008;10(1):35– 42.
3. Callan P et al. Clin Cosmet Investig Dermatol. 2013;6:81–89.
4. De Boulle K et al. Dermatol Surg 2013;39:1758–66.
5. Borrell M et al. J Cosmet Laser Ther 2011;13:21–7.
6. WO2004/092222A2 patent.
7. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147–158.
8. Raspaldo H. J Cosmet Laser Ther. 2008;10:134–142.
9. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172.
10. DFU for Juvéderm® VOLUMA® with Lidocaine 72475JR11.
11. DFU for Juvéderm® ULTRA PLUS XC™ 72383JR11.
12. DFU for Juvéderm® ULTRA XC™ 72525JR10.
13. Sherman, R. Clinics in Dermatology, 2009; 27, S23–S32.
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